Thomas Lear — Suicide (from 2015)

Date of report	11 Oct 2018
Deceased	Thomas Lear
Coroner	Margaret Jones
Coroner area	Stoke-On-Trent and North Staffordshire
Category	Suicide (from 2015)
Source	judiciary.uk record · original PDF
Responses published	none published

The report

Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.

TAN S SMITH
LL.B, Hon DUniv
HER MATESTY’S CORONER

CORONER’S CHAMBERS,
547 HARTSHILL ROAD,
STOKE-ON-TRENT ST4 GHF
Tel: (01782) 234777
Fax: (01782) 232074
Email: coroners@stoke.gov.uk

for the
Steke-on-Trent and North Staffordshire
Coroner’s Area

nn een
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

1. FB tongton Police station, Sutherland Road, Lengton, Stoke-on-Trent, ST3 1HH

THIS REPORT iS BEING SENT TO: |
:

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lo 2 Ea Longton Police Station, Sutherland Road, Longton, Stoke-on-Trent, ST3
i

| 1HH
| 3. aay Stewart OBE MP, Minister of State, Ministry of Justice, Petty France, London, SW1H
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| CORONER i
i !
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| iam Margaret J Jones HM Assistant Coroner for Stoke-on-Trent & North Staffordshire |
ee ee ed
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During the course of the inquest the evidence revealed matters giving rise to concern. In my
opinion there ts a risk that future deaths will occur unless action is taken. In the circumstances it
is my statutory duty te report to you.

Pope

| CORONER'S LEGAL POWERS

i

i make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and /
i regulations 28 and 29 of the Coroners (investigations) Regulations 2013. |
| | http://www. legislation gov.uk/ukpea/2009/25/schedule/5/paragraph/? :
j | htto.//www. legislation. gov.uk/uksi/2013/1629/part/7/made i
: i ee _ _ . ee |
| 3 | INVESTIGATION and INQUEST —

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| | On 17/01/2018 | commenced an investigation into the death of Thomas Philip Lear. The |
| / investigation concluded at the end af the inquest 10th October 2018. The conclusion of the |
_ inquest was suicide: _ a a |
4 | CIRCUMSTANCES OF THE DEATH
: | The deceased was a 39 year old single male who had no permanent address after being released :
i from prison and was currently staying with his ex-partner at i
| HB i's medica! history included drug misuse, anxiety, depression and previous suicide
i attempts. He was last seen by his ex-partner at 8.20 pm on the 6th January 2018 when she
: | asked him to leave the address as he had returned under the influence of drugs. He returned to /
i : the address and after being asked to leave again made a threat to hang himself. At1040pma_ |
/ | friend found him hanging from a fence post in the back garden of his partner's property. i
/ Paramedics and police attended and death was confirmed at 11.16 pm on 6th January 2018. :
i | Toxicology confirmed he had used a number of illicit drugs. There was no third party
/ | involvement. The cause of death given was:-
i : ‘ia Asphyxia.
L _ibHanging. _ oe _ 7
|5 | CORONER’S CONCERNS

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| The MATTERS OF CONCERN are as follows. —
| (1} The deceased had been released from prison on the 29" December 2018. He was homeless
and lapsed quickly back into drug taking. An ex-partner offered him some temporary

ANG 1aPSeG QUICKY BACK Into GPUs Taking. An ex-parther OMeree HN SOME TEMporary

| accommodation. On the 6” January she refused him admission to her house because he was |
clearly under the influence of drugs. Shortly after he hung himself in the rear garden at her |
address. it was not apparent at the inquest that any help had been offered to the deceased with |
| regards to accommodation following his release from prison. i
| (2) On Saturday 6" Ja nuary 2018 he threatened to hang himself. At 3.37pm and at 5.03pm that
day the mother of the deceased sent two text messages to the mobile phone offs '
_ allocated Integrated Offender Manager (IOM) indicating that he had threatened to hang himself.
i | The 1OM phone number is only available Monday-Friday and there was no apparent divert to any

| other number which might have picked up the urgent nature of the text messages. mi

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/ _ ACTION SHOULD BE TAKEN “]
: In my opinion action should be taken to prevent future deaths and | believe that you or your i
: organisation has the power to take such action.
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| 7 | YOUR RESPONSE i
i | You are under a duty to respond to this report within 56 days of the date of this report, namely !
| by Friday 7° December 2018. |, the coroner, may extend the period, i

i Your response must contain details of action taken or proposed to be taken, setting out the :
timetable for action. Otherwise you must explain why no action is proposed. i
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"COPIES and PUBLICATION
i have sent a copy of my report to the Chief Coroner and to the following Interested Persons:-

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FY mother of the deceased.

iam also under a duty to send the Chief Coroner a copy of your response.

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i The Chief Coroner may publish either or both in a complete or redacted or summary form. He
| may send a copy of this report to any person who he believes may find it useful or of interest. /
» You may make representations to me, the coroner, at the time of your response, about the |
: release or the publication of your response by the Chief Coroner. {
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Prt/10/2018 ~

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| Signature, : 4 se a eo
_ Margaret J Jones MM Assistant Coroner Stoke-on-Trent & North Staffordshire

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